Provider Demographics
NPI:1407997117
Name:OLIVER, TRACY SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:SCOTT
Last Name:OLIVER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 KITTIWAKE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-4923
Mailing Address - Country:US
Mailing Address - Phone:757-422-1317
Mailing Address - Fax:757-961-2771
Practice Address - Street 1:2484 N LANDING RD
Practice Address - Street 2:SUITE 114
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3405
Practice Address - Country:US
Practice Address - Phone:757-471-5480
Practice Address - Fax:757-471-7859
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007137122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist